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ANARCUIR-PWIN TO A'MMr SEM LLRAN*D
CITY OF SALEM
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PLEASE F LL OUr LEGMY&OONPLXWELY TO AVOW ONLAVS N PROONliN10
TO THE INSPECTOR OF SUILDING&
hwoby appios for a pwmk to bukd a000rditto tha.toNollrklp
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4 COBURN RD.
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DEPOSAL C)F DEBRX AFFIDAVIT
b aaoadanos wft the p mviaiaos of 11 M a 406 83/►I ael000wWp due•a coodidam
of Bml ft Pawn 0 .sit ddob resod ft Mms to cooatroc"aadv*
joves"bylibDoOduPp k sW be diapossd offs a*qpo llr Hammed saW wwom
dbposd hcMW,r desired by lido,a iL 8110A.
Mw debris wM bs dtspoaed of at
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Adams City&Stab
Mw above atamis tegoirea that debris 5om the df®oHdao, rumo ioo,rehab or albs
si0mod n of bO ft or structure be disposed ID a p(rperly4icrosed a did vagm ditpo d
Amc ty a defined by MM cUL SIM,and the buiktio8 PM"
licmaas sm m
barn s the beadm of ew heft.
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do hereby'csrdy under tfe pates and po Mo„f pee eq, dm
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I am a tok proprlawr and hove so mw woMM fir me to aq opedq.
O 1 am a tole proprietor, =moral o Ml3Mll w or homevwnv (dreh owe) sad;how hhd dw
UMMaots lbtd below who-heva tbi feiNowk4 worker eoalpeasulea peYdeit
' Ooravaeeor Iraorsnta C.ora�y/
Gomracsor Inwnnci company/sky Huge"
Ceaaaetor inatrana Cornpaay/ o N
0 1 am a homeowner performing so,on work mynff.
r„ea.raaae na a cae►N ai arms we be br.araea a are Olin A revepaao N ar OIA M ee.er w wAater aia an Irlra w ows
ewenp a rawro war Inert..ttA N FCA 152 ear lose a ew Woudw N alerfee"noft taemMM N a Am d w wi IJOON aeeler w
+eaq'irrr.rwar a a ad.caste in eM term a!a STOP WORK ORO ER ace a ire oft 100A0 a onint.p ae.Signed chit . day of ,. U I/ aoo y
:ucraccl'Fcrtnit[ee is tl Ind Gep rinreri
etvin; Score
Seiectmew Office
rialth Geponmer;
-_45CC = 5 _ : AO` 405, 4oe 7ic
Board of Bullding Regulations and Standards
HOME IM�ROVEMENTCONTRACTOR
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lament Care!
THE Home De '` "'''��!
MNROEUN CHH,, �1�
3200 COBS GALLE `riR
ALTANTA,GA 30339 y. CL.... r�.�.,�
_ _ Adminl�-__